Transcript Abstract - WHO archives

Can pharmacists improve outcomes in hypertensive patients?
Sookaneknun P (1), Richards RME (2), Sanguansermsri J(1),
Teerasut C (3) : (1)Faculty of Pharmacy, Chiang Mai University,
Thailand; (2) Faculty of Pharmaceutical and Health Sciences,
Mahasarakham University, Thailand ; (3) Mahasarakham Hospital,
Thailand
Abstract
Problem Statement: Hypertension is an asymptomatic chronic
condition that is strongly associated with cardiovascular complications
such as stroke, myocardial infarction, angina, nephropathy, peripheral
arterial disease, and retinopathy. It is reported in the literature that 5
mm Hg reduction in diastolic blood pressure can reduce the risk of
stroke by 35%-40%, and of coronary heart disease by 20%-25%.
Objective: To evaluate the effect of pharmacist involvement with
hypertensive patients in community pharmacies and in primary care
units. Design: Randomized, pre- post-test control group design.
Analysis of covariance, multiple logistic regression and chi-square test
were used to analyze blood pressure results. The p value was set at <
0.05. Setting and Population: Mahasarakham University pharmacy, 1
kilometer from the provincial hospital, and 2 primary care units, located
in an area 3 kilometers around the University. Hypertensive patients
were randomly assigned to a treatment group (pharmacist involved) or
a control group (no pharmacist involved). There were 235 eligible
patients (118 treatment and 117 control). Intervention: Individualized
care by the research pharmacist monitoring blood pressure in the
treatment group every month; education materials; assessment of
adherence to treatment; dealing with drug related problems; and
providing non pharmacological treatment. If the research pharmacist
found the drug related problems, the patient would be referred to a
doctor in the hospital. Outcome measures: Blood pressure at pre-test
and post-test periods. The study began in October 2002 and ended at
the end of July 2003. Results: From the total number of 235 patients,
the ‘pharmacist involved group’ had a significant reduction in both SBP
(p=0.037) and DBP (p=0.027) when compared with the ‘no pharmacist
involved group’. The results were similar for 158 patients who had high
blood pressure at the beginning of the study (p=0.002 and 0.008, for
SBP and DBP, respectively). The logistic regression also confirmed that
the patients were more controlled in the ‘pharmacist involved group’
than in the ‘no pharmacist involved group’ (odds ratio = 1.849, in SBP).
The ‘no pharmacist involved group’ also showed a significant
improvement in blood pressure over the study period but the
‘pharmacist involved group’ had a significantly better reduction in blood
pressure. Conclusions: Our results indicate a definite benefit to
hypertensive patients outcomes from the involvement of a pharmacist in
their care in the primary care setting. This should result in a significant
increase in the life expectancy of this group of patients.
Background and setting
Hypertension is an asymptomatic chronic
condition associated with cardiovascular
complications such as stroke, myocardial
infarction, angina, nephropathy, peripheral
arterial disease and retinopathy.
It is considered that pharmacists are
critical to the success of programs designed
to improve blood pressure control rates
(ASHP report, 2000). In fact it has been shown
more than 25 years ago that community
pharmacists can have an important role in
assisting primary care physicians in managing
patients with hypertension (McKenney et al.,
1973, Carter BL, 1997).
Several studies showed that clinical
pharmacist services are effective in the
treatment of hypertension, as demonstrated
by improvements in patients’ knowledge,
compliance with medication regimens and
blood pressure measurements. (Monson R et
al, 1981, Morse GD et al, 1986, Cookson T et al,
1997, Erickson SR et al, 1997 and Solomon DK
et al, 1998).
Study question
• Can pharmacists improve outcomes in
hypertensive patients?
Methods
• Design: randomized, pre- post- test control
group design
• Setting and population: 1 Mahasarakham
University Pharmacy and 2 primary care
units. The patients were randomly assigned
to a treatment group and a control group.
• Intervention: Individualized care by the
research pharmacist monitoring blood
pressure in the treatment group every
month; education materials; assessment of
adherence to treatment; dealing with drug
related problems; and providing non
pharmacological treatment. If the research
pharmacist found the drug related problems,
the patient would be referred to a doctor in
the hospital.
• Outcome measure: blood pressure at pretest and post-test period (6 months)
• Analysis: analysis of covariance for the
blood pressure difference between groups,
Paired t test for the comparison between pre
and post test, Multiple logistic regression for
the controlled blood pressure difference
between
groups,
Chi
square
for
characteristic baseline comparison between
groups
Results
• There were 235 patients included in the study
and there were 158 patients who had high
blood pressure during the pre test period.
• Results of randomization in all variables
showed no different between the control and
treatment group as shown in Table 1.
• After 6 months, the mean of blood pressure
reduced in both groups as in Table 2, but
there was more reduction in the treatment
group. When comparing between treatment
and control group, we found that the
treatment group showed reductions in both
systolic and diastolic blood pressures
compared to the control group shown in
Table 3.
• The treatment group showed more control
only in systolic blood pressure. In 158
patients who had high blood pressure during
the pre test, the treatment group showed
more control both in systolic and diastolic
blood pressure as shown in Table 4.
Table 1 Homogeneity of demographic variables
between groups at the baseline (N = 235 patients)
Demographic variables
Sex
Men
Women
Age, mean (SD)
Career
Business
Government employee
Farmer
Business employee
Retired employee
No career (home
maid)
Education
No education
Primary school
Secondary school
Pre bachelor degree
Bachelor degree or
higher
Marital status
Widow
Divorce
Married
Single
SBP, mean (SD)
DBP, mean (SD)
SBP/DBP*
Controlled HT
Uncontrolled HT
Total
SBP/DBP**
Controlled HT
Uncontrolled HT
Total
Treatment group
(n=118)
Control group
(n=117)
P value
exp
(b)
0.224
42
76
33
84
63.20 (9.33)
63.23 (9.25)
0.982
0.695
21
9
31
5
9
51
19
12
30
2
0
53
0.229
1
83
22
4
8
2
81
17
2
15
0.130
32
7
76
3
37
2
70
8
144.76 (19.69)
85.72 (13.56)
143.41 (19.81)
85.96 (12.94)
32/64
86/54
118/118
36/57
81/60
117/117
5/21
71/55
76/76
7/26
75/56
82/82
0.600
0.889
0.537/
0.398
0.837/
1.248
0.398/
0.576
1.248/
0.822
HT= hypertension, *Controlled or uncontrolled definition followed
JNC VI, ** in the sample of 158 patients who had high blood
pressure level, > 140/90 mm Hg, during the pre test
Table 2 Blood pressure means in the pre test and
post test periods
Variable
N = 235
Pre test
SBP
DBP
Post test
SBP
DBP
Paired difference
SBP
DBP
N = 158
Pre test
SBP
DBP
Post test
SBP
DBP
Paired difference
SBP
DBP
Treatment group
Mean (SD)
Control group
Mean (SD)
144.76 (19.69)
85.72 (13.56)
143.40 (19.81)
85.96 (12.94)
121.47 (14.90)
71.55 (10.80)
124.77 (17.97)
74.23 (11.87)
23.29 (19.10)
14.18 (11.20)
18.64 (17.67)
11.73 (10.08)
155.19 (15.51)
90.47 (13.85)
152.19 (16.17)
89.73 (12.96)
124.16 (14.23)
73.08 (10.68)
130.36 (16.83)
76.52(12.35)
26.26 (18.14)
15.22 (10.95)
21.83 (17.84)
13.22 (10.37)
Table 3 Results of the analysis of covariance model
evaluating the effect of pharmacist involvement on
the blood pressure of hypertensive patients after 6
months
N=235
SBP post test
DBP post test
N = 158
SBP post test
DBP post test
treatment
group
control
group
p
value*
124.16
(14.23)**
73.08
(10.68)**
130.36
(16.83)**
76.52
(12.35)**
0.037
121.47
(14.90)**
71.55
(10.80)**
124.77
(17.97)**
74.23
(11.87)**
0.002
0.027
0.008
•p value of the analysis of covariance use pre test as a
covariate
** means significant difference (p = 0.000)
Table 4 Blood pressure differences between no
pharmacist involved and pharmacist involved groups
at the pre test period and the post test period (after 6
months)
Variables
N = 235
SBP
Treatment
group(1)
SBP pretest
DBP
Treatment
group(1)
DBP pretest
N = 158
SBP
Treatment
group(1)
SBP pretest
DBP
Treatment
group(1)
DBP pretest
p
exp(b)
CI(odds)
0.044
0.000
1.849
6.436
1.017-3.363
2.611-15.862
0.088
0.000
1.852
5.219
0.912-3.762
2.363-11.530
0.012
0.050
2.387
8.122
1.214-4.693
1.004-65.685
0.033
0.003
2.208
4.311
1.066-4.573
1.662-11.186
CI = confidence interval of 95%, exp (b) = odds ratio
Summary
• Our results indicate a definite benefit to
hypertensive patients outcomes from the
involvement of a pharmacist in their care in
the primary care setting. This should result in
a significant increase in the life expectancy
of this group of patients.
Discussion
• Blood pressure reduction in both groups
were reduced significantly. That might be
because this time of the study was the time
of good heart good health of the province.
There were many activities such as group
exercise, health education and some trips
outside the province for hypertensive
patients.
• We showed the results of 2 groups of total
eligible patients, 235, and high blood
pressure at the pre test period, 158.
Pharmacists can help hypertensive patients
to have better control and more reduction in
blood pressure especially in the high blood
pressure sample which is supported by other
studies.
Conclusions and
recommendation
• Pharmacists have an important role in
monitoring and providing care for chronic
conditions such as hypertension to achieve
more control in blood pressure. This applies
especially the pharmacy where patients can
easily be contacted.
• If possible, pharmacists should provide care
for longer period of time to see the results
on morbidity and mortality.